﻿<?xml version="1.0" encoding="utf-8" ?>
<TransactionSpecification xmlns="http://tempuri.org/X12ParserSpecification.xsd"  TransactionSetIdentifierCode="278">
  <Segment SegmentId="BHT"/>
  <HierarchicalLoop LoopId="2000A" LevelCode="20">
    <Name>Utilization Management Organization (UMO) Detail</Name>
    <Segment SegmentId="AAA"/>
    <Loop LoopId="2010A">
      <Name>Utilization Management Organization (UMO) Name</Name>
      <StartingSegment SegmentId="NM1"/>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="AAA"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000B" LevelCode="21">
    <Name>Requester Detail</Name>
    <Segment SegmentId="PWK"/>
    <Loop LoopId="2010B">
      <Name>Requester Name</Name>
      <StartingSegment SegmentId="NM1"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="PRV"/>
      <Segment SegmentId="AAA"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000C" LevelCode="22">
    <Name>Subscriber Detail</Name>
    <Segment SegmentId="PWK"/>
    <Loop LoopId="2010C">
      <Name>Subscriber Name</Name>
      <StartingSegment SegmentId="NM1"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="AAA"/>
      <Segment SegmentId="DMG"/>
      <Segment SegmentId="INS"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000D" LevelCode="23">
    <Name>Dependent Detail</Name>
    <Segment SegmentId="PWK"/>
    <Loop LoopId="2010D">
      <Name>Dependent Name</Name>
      <StartingSegment SegmentId="NM1"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="AAA"/>
      <Segment SegmentId="DMG"/>
      <Segment SegmentId="INS"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000E" LevelCode="EV">
    <Name>Patient Event Detail</Name>
    <Segment SegmentId="TRN"/>
    <Segment SegmentId="AAA"/>
    <Segment SegmentId="UM"/>
    <Segment SegmentId="HCR"/>
    <Segment SegmentId="REF"/>
    <Segment SegmentId="DTP"/>
    <Segment SegmentId="HI"/>
    <Segment SegmentId="HSD"/>
    <Segment SegmentId="CRC"/>
    <Segment SegmentId="CL1"/>
    <Segment SegmentId="CR1"/>
    <Segment SegmentId="CR2"/>
    <Segment SegmentId="CR5"/>
    <Segment SegmentId="CR6"/>
    <Segment SegmentId="PWK"/>
    <Segment SegmentId="MSG"/>
    <Loop LoopId="2010EA">
      <Name>Patient Event Provider Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="71">Attending Physician</EntityIdentifier>
        <EntityIdentifier Code="72">Operating Physician</EntityIdentifier>
        <EntityIdentifier Code="73">Other Physician</EntityIdentifier>
        <EntityIdentifier Code="77">Service Location</EntityIdentifier>
        <EntityIdentifier Code="AAJ">Admitting Services</EntityIdentifier>
        <EntityIdentifier Code="DD">Assistant Surgeon</EntityIdentifier>
        <EntityIdentifier Code="DK">Ordering Physician</EntityIdentifier>
        <EntityIdentifier Code="DN">Referring Provider</EntityIdentifier>
        <EntityIdentifier Code="FA">Facility</EntityIdentifier>
        <EntityIdentifier Code="G3">Clinic</EntityIdentifier>
        <EntityIdentifier Code="P3">Primary Care Provider</EntityIdentifier>
        <EntityIdentifier Code="QB">Purchase Service Provider</EntityIdentifier>
        <EntityIdentifier Code="QV">Group Practice</EntityIdentifier>
        <EntityIdentifier Code="SJ">Service Provider</EntityIdentifier>
      </StartingSegment>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="AAA"/>
      <Segment SegmentId="PRV"/>
    </Loop>
    <Loop LoopId="2010EB">
      <Name>Patient Event Transport Information</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="45">Drop-off Location</EntityIdentifier>
        <EntityIdentifier Code="FS">Final Scheduled Destination</EntityIdentifier>
        <EntityIdentifier Code="ND">Next Destination</EntityIdentifier>
        <EntityIdentifier Code="PW">Pickup Address</EntityIdentifier>
        <EntityIdentifier Code="R3">Next Scheduled Destination</EntityIdentifier>
      </StartingSegment>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
    </Loop>
    <Loop LoopId="2010EC">
      <Name>Patient Event Other UMO Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="00">Alternate Insurer</EntityIdentifier>
        <EntityIdentifier Code="CA">Carrier</EntityIdentifier>
        <EntityIdentifier Code="GG">Intermediary</EntityIdentifier>
      </StartingSegment>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="AAA"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000F" LevelCode="SS">
    <Name>Service Detail</Name>
    <Segment SegmentId="TRN"/>
    <Segment SegmentId="AAA"/>
    <Segment SegmentId="UM"/>
    <Segment SegmentId="HCR"/>
    <Segment SegmentId="REF"/>
    <Segment SegmentId="DTP"/>
    <Segment SegmentId="HI"/>
    <Segment SegmentId="SV1"/>
    <Segment SegmentId="SV2"/>
    <Segment SegmentId="SV3"/>
    <Segment SegmentId="TOO"/>
    <Segment SegmentId="HSD"/>
    <Segment SegmentId="PWK"/>
    <Segment SegmentId="MSG"/>
    <Loop LoopId="2010F">
      <Name>Service Provider Name</Name>
      <StartingSegment SegmentId="NM1"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="N3"/>
      <Segment SegmentId="N4"/>
      <Segment SegmentId="PER"/>
      <Segment SegmentId="PRV"/>
    </Loop>
  </HierarchicalLoop>
</TransactionSpecification>